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More Sports, More Risk

IN the spring of his fourth grade year, Hunter Berman of Chappaqua was playing baseball, lacrosse, tennis and soccer. Hunter's baseball coach noticed that Hunter, then 9, seemed to be throwing from the side of his arm instead of pitching fully from overhead. At the coach's suggestion, Hunter's parents took him to an orthopedist, who discovered a stress fracture in the growth plate of the child's shoulder. The doctor diagnosed the fracture as an overuse injury.

''The theory was that doing three sports that involved rotation of the shoulder probably created a stress environment in this one area,'' said Hunter's mother, Robyn. ''We took that as a warning sign that you need to be careful from now on. We buckled down after that and said only one sport that uses that motion.''

Hunter, now 13, still has problems with his shoulder. He plays baseball but does not pitch. He uses a modified tennis serve. He still plays soccer, lacrosse and basketball. Mrs. Berman believes that keeping Hunter active in a variety of sports will reduce his chances of further injury. Hunter's doctor said he should avoid playing multiple sports, which involve using the same motion, in one season.

When Kate McCormick of Pelham was hurt, she was playing soccer. Kate, 15, loves soccer so much that last spring, she was playing for three different soccer teams: her high school varsity team; a club travel team, the Eastchester Patriots; and an Olympic Development Team, a highly selective state team. She attended varsity practices every day after school, club team practices three times a week and state team practices in Albany every Monday. There were also games on the weekends.

The injury that put a quick -- and she hopes temporary -- stop to her soccer career was the result of a collision. She and an opposing player kicked the ball at the same moment; the other girl fell onto Kate, jamming her knee into Kate's knee. Kate tore her anterior cruciate ligament (ACL) on her right knee.

''The pain was excruciating,'' Kate said. ''I heard a pop and I knew enough from playing soccer to think, 'Oh my God, I hope I didn't just tear my ACL.' ''

It was a moment, Kate's mother, Elaine said, ''that no mother should see her child go through.''

Visit a physical therapy center in Westchester and it is not only filled with a generation of baby boomers nursing the aches and pains of middle age. But it is also likely to be populated by their children, recovering from a variety of sports injuries, rehabilitating knees, hips, elbows, ankles and shoulders.

While many American children get too little physical activity -- 13 percent of the nation's children are classified as seriously overweight, a number that has more than doubled in the last two decades -- in suburbs where children's soccer or hockey or softball schedules dominate the family calendar year round, at least some doctors, parents and coaches are beginning to ask how much athletic activity is too much?

D OCTORS who specialize in the new field of sports medicine for children say more young people are getting injured playing sports, and they point to a number of causes. First, in previous generations, children did not play so many organized sports. There was much more unstructured play -- a pickup basketball game here, some neighborhood baseball there -- but children didn't practice with the rigor they do today, with repetitive drills, lap running and scrimmages. In earlier days, when a child became tired of playing, he or she stopped. Today, practices for children can run three hours.

A generation ago, specific sports were played during one season. Boys may have played football in the fall and baseball in the spring. But now, many sports are played all year. Baseball leagues play and practice in the spring, summer, winter and fall; so do some soccer and lacrosse teams.

Children are also specializing in one sport at younger ages. Children as young as 10 are encouraged by parents and coaches alike to devote themselves to whichever sport they show the most promise in, be it ice hockey or tennis. In sports like gymnastics and dance, the pressure to specialize comes even earlier.

''Our soccer coach is fanatical,'' said a mother in Scarsdale who did not want to identify herself because she feared retribution for her 10-year-old son. ''He pushes hard, yells a lot and he made a rule that you can't miss a practice if it relates to another sport. Religious reasons or family reasons are O.K., but you can't be playing another sport.''

The number of travel teams, which hold tryouts, practice during the week and play games against teams from other cities or towns in the region, has also grown substantially. Fifteen years ago, travel teams were rare. Now, it's the rare town that doesn't have travel teams, for basketball, baseball, soccer, hockey, starting for children as young as 8. The result is that children are not only extending their seasons, but also playing their sport in multiple leagues, including recreational teams, school teams and club teams. And while some children may play one sport year round, still others, like Hunter, play several different sports in one season, also a relatively new phenomenon.

All of this puts children at higher risk for overuse injuries, said Dr. Eric Small, director of the Sports Medicine Center for Young Athletes at Blythedale Children's Hospital in Valhalla. Dr. Small said that between 60 to 75 percent of the injuries he sees in children are from overuse. He added that the patients he is seeing are getting younger, with 8-year-olds complaining of tendonitis and heel pain.

Early specialization contributes to overuse because it tends to create muscle imbalance, Dr. Small said. If only one sport is played constantly, one muscle -- the quadricep, for instance -- may be highly developed while the hamstring is not. When there is too much pull on the less developed muscle, injury can occur.

Children and teenagers are also particularly vulnerable to overuse injuries because they are still growing, Dr. Small said. Growth plates, which are made up of soft tissue, are at the tips of maturing bones, and they often aren't strong enough to handle constant pounding or the stress of a repetitive motion. Many overuse injuries occur when children are at their peak growth spurts, Dr. Small said.

Officials from Little League baseball recognized this many years ago, and issued regulations limiting the number of innings a player could pitch, to protect young shoulders and elbows. But Little League regulations do little to limit the child who plays in three different baseball leagues.

''You really see these injuries when kids play on multiple teams,'' said Dr. Howard Luks, chief of Sports Medicine at the Westchester Medical Center in Valhalla. ''There is supposed to be a limit and beyond that you're not supposed to be throwing. It's not to punish them or to allow other children to play. It's to prevent injury and if they think the clock resets when they go to their traveling team, they are mistaken.''

Children who specialize in one sport early are not only at risk for overuse injuries but also for mental burnout, said Rick Wolff, a sports psychology expert in Armonk, who discusses parenting issues on ''The Sports Edge,'' his Sunday morning talk show on WFAN-AM (660).

''I know of no study that says if your child specializes in one sport at an early age, that's going to guarantee them to be a star when they get to be in high school or college,'' Mr. Wolff said. ''Conversely I know of many studies that say that kids who specialize in one sport run a very serious risk of burning out and leaving the sport by the time they're 13 or 14.''

Mr. Wolff said that he often hears children say things like, ''I play soccer seriously but I play basketball for fun,'' raising the question of when sports for children became more of job then an activity for fun and fitness.

Thomas Burns, a certified athletic trainer at Fox Lane High School in Bedford, said that for college athletes, sports often becomes a full-time job, with football players beginning practice in July, and workouts continuing throughout the off season. But now, he said, this phenomenon seems to be spreading to younger athletes.

''This is starting to spill back from college into high school, and now sometimes into the middle school,'' Mr. Burns said. ''I think it's too much.''

Where is the pressure coming from? Everywhere, say those who work with young athletes. Parents want their children to succeed on the athletic field. Coaches want the best performances out of their teams. And children themselves want to perform at high levels. Those who love sports want to play for as many hours a day as they can. When an injury occurs, doctors report that families often have a difficult time accepting that the child needs a rest.

''Benching a child is a very difficult thing to do from my side,'' Dr. Luks said. ''It's not as easy as talking to a parent and saying, ''O.K., your kid can't play,'' because that night I'm going to get a phone call from the father saying I'm an idiot and he's going to get a second opinion, and you're definitely going to get a call from the coach, because everyone's child is the best on the team and has the prospect to be the next Tiger Woods.''

Dr. Small said he often is providing the second or third opinion to young athletes and their parents who just can't accept that the child needs to cut back on the activity or at least do some cross training.

''I was the third opinion for one 15-year-old girl who was running 50 or 60 miles a week, which is more than adult marathoners run,'' Dr. Small said. ''In the past year, she'd had knee braces and orthopedics and ankle supports. None of them worked. It was just that she was running too much.''

Dr. Small said that often well-meaning parents who push their children athletically had not themselves played at a competitive level, and that they didn't understand some of the demands they were making. Former college-level athletes tend to be more relaxed about their children's performance, he said.

OF course, young athletes themselves want to play and they want to play well. Kate, who had been playing soccer since she was 4 1/2, was crushed to be out of action. After her accident, she began working out with a physical therapist and she hopes to able to try out this November to regain her place on the Olympic Development Team.

''In the beginning months I was just torn to pieces not being able to play soccer, which I love to do,'' Kate said. She added that her teammates' support has helped her get through her recovery.

It is unclear what causes ACL tears like the one Kate suffered. Dr. Small said he has seen an epidemic of ACL tears among girls in his practice. The ACL is one of the two main stabilizing ligaments of the knee joint. It can tear when a great amount of force is placed on the knee or when the knee rotates excessively, most often occurring when landing from a jump, stopping suddenly or pivoting.

Dr. Small noted that some of the medical literature indicates that girls have looser ligaments than boys as one reason they are more susceptible to ACL injuries. Another theory is that ACL tears may be a type of overuse injury, in which muscle imbalance plays a role. In sports like soccer and basketball, athletes' quadriceps are very strong while hamstrings may not be as well developed. Some argue that girls are less likely to go through the strength training that boys do, and this makes them more vulnerable to injury.

Kate had been working with a strength trainer before her collision and believes that the preventative work she did kept the injury from being worse and is speeding her recovery. Athletes who have ACL surgery are usually on crutches for about four weeks after surgery, and can resume sports in about six months.

Drew Werner, a 17-year-old lacrosse player from Somers, knows more about ACL tears than any teenager should -- he has already had two. The spring of his sophomore year, Drew said he ''cut the wrong way'' during practice and was injured so badly he couldn't walk off the field. He had knee surgery that June. He continued with physical therapy through the summer and fall, which knocked out the soccer season for him, too.

When winter came, Drew figured he could play again if he took it easy. In a pickup lacrosse game, he was pushed from behind, tried to plant his knee, and it happened again: He tore the same ligament in the same knee. This time, he had company during his recovery: his older brother Tommy, who had been playing lacrosse for Fairfield University, had ACL surgery on his knee the week before Drew did. Like Kate, being out of play was miserable for Drew.

''It was terrible just sitting on the sidelines for the rest of the year when we made it to the state semifinals,'' he said. ''Then the same thing for the soccer season. When I was sitting out I would have done anything just to start playing again.''

To be sure, in their concern about sports injuries, doctors are not advocating that children and teenagers lead inactive lives. Dr. Small, himself an athlete and coach, points to the many advantages of sports for children -- both psychological and physical. He said that his goal was to help prevent and treat injuries in young athletes to allow them to participate fully in their sports wherever appropriate.

''We know that physical activity is vital for all children,'' Dr. Small said. ''Yet we should ask, 'Are sports and physical activities being taught and performed with the well-being -- present and future -- of the children uppermost in our minds? Or are we pushing them too far, too fast?' ''

Ways to Prevent Injuries

THERE are ways to ward off injuries caused by overuse.

Dr. Eric Small, director of the Sports Medicine Center for Young Athletes at Blythedale Children's Hospital in Valhalla, recommends that athletes cut back on training during growth spurts, incorporate flexibility exercises into their workouts and pursue cross-training. He stresses the importance of a good muscle strengthening program before the start of a sports season, and stretching and warming up before every practice and game.

Recognizing early signs -- pains in tendons, pain that worsens with an activity or after an activity -- is important, and a doctor should be consulted to prevent the worsening of the injury.

Many high schools in Westchester have begun programs to lower injury rates by hiring certified athletic trainers to complement their coaching staffs. These trainers provide basic sports medicine to the students, taking care of them when they are hurt, but also trying to prevent injuries.

Thomas Burns, a certified athletic trainer at Fox Lane High School in Bedford, said he has developed strength training programs for specific sports, corrected some training mistakes that could lead to injuries, and worked on flexibility with young athletes. He also educates members of the coaching staff.

He said adolescents are often at risk because of training errors, using improperly sized equipment and increasing the number of hours of practice a week too quickly.

''One of the reasons we have trainers out in the schools is that we've identified a real need,'' Mr. Burns said. ''A lot of kids were participating in sports and a lot of kids were getting hurt and a lot were not being cared for properly. You're required to have a nurse during school hours, but your higher risk activities are after school on the playing fields.'' KATE STONE LOMBARDI